Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

The Medicare Advantage quality bonus program provides financial incentives to Medicare health insurers based on the star ratings of their plans [1]. Depending on how Medicare Advantage plans perform on a series of quality measures, they are assigned a star rating, from one to five. A higher star rating means greater financial incentives, so performance on the measures is important for insurers’ bottom line.

Currently, Medicare Advantage has one measure specific to mental health: Improving or Maintaining Mental Health. This measure assesses how well beneficiary’s mental health needs are attended to, based on an annual survey that asks a series of questions about their mental health.Medicare Advantage also has other measures that include people with MH/SUD, although are not specific to MH/SUD. Plan All-Cause Readmissions assesses the extent to which people are quickly readmitted to the hospital after discharge, which can include factors related to MH/SUD conditions. An array of patient experience measures also cover those with MH/SUD, including GettingAppointments and Care Quickly, Rating of Health Care Quality, and CareCoordination. Plans must also report on their efforts to improve quality, which can include initiatives that impact MH/SUD.

To better address the full range of MH/SUD needs, the Improving or Maintaining Mental Health measure could be expanded to also cover addiction. The more general measures that include MH/SUD should also be disaggregated to provide separate incentives for beneficiaries with MH/SUD conditions, given the siloed history of MH/SUD care. By focusing attention onMH/SUD needs, Medicare Advantage plans will have stronger financial incentives to integrate MH/SUD care into overall health. Separate reporting of quality improvement in MH/SUD will also give health plans credit for the initiatives they implement to achieve this integration.

Across Administrations, CMS has pursued reforms designed to build up primary care as a key strategy for achieving better care at lower costs, especially in Medicare. For example, CMS developed new Advanced PrimaryCare Management (APCM) codes in Medicare to better compensate primary care providers for their work in coordinating longitudinal care management [1].Other efforts focus on providing more incentives for primary care in value-based payment arrangements [2]. To date, these efforts have not fully compensated primary care for the costs and effort to implement evidence-based models ofMH/SUD care integration. MH/SUD must be central to reforms promoting advanced primary care.

CMS should set quantitative goals for access and quality related to integrated MH/SUD care. CMS should publicly report progress toward these goals so that stakeholders can engage in identifying and addressing barriers. To promote progress, CMS should build on the APCM codes to recognize the importance of delivering evidence-based integrated MH/SUD care and compensate accordingly. CMS should also further incentivize primary care to take on relevant quality improvement activities on MH/SUD integration (such asCompletion of Collaborative Care Management Training Program or Implementation of Integrated Patient Centered Behavioral Health Model, among others). Across programs, CMS should pay for quality performance for both screening and outcomes focusing on MH/SUD (such as Preventive Care and Screening: Screening for Depression and Follow-Up Plan, Initiation and Engagement of Substance UseDisorder Treatment, and Screening for Social Drivers of Health, Improvement orMaintenance of Functioning for Individuals with a Mental and/or Substance UseDisorder or Depression Remission at Twelve Months, and Consumer Assessment ofHealthcare Providers and Systems). In value-based payment arrangements, CMS should waive the costs of MH/SUD integration from counting against shared savings, or otherwise include the expected spending in the shared saving benchmark calculations.

Although regulatory changes have removed some barriers to prescribing medications for substance use disorders — such as the elimination of thefederal X-waiver requirement for buprenorphine [1] — access to MOUD and MAUD remains limited, particularly among older adults and those transitioning out ofhospital settings. Recent research finds that only 5% of individuals with opioid use disorder (OUD) discharged from inpatient hospitalization receive MOUD, and just 2% of individuals with alcohol use disorder (AUD) receive MAUD after hospitalization.[2] Hospitals and post-acute settings represent critical intervention points for initiating or continuing evidence-based medications for addiction treatment, particularly for aging adults, whose rates of substance use and overdose have been steadily rising.[3] Requiring MOUD and MAUD availability as part of Medicare’s Conditions of Participation (CoPs) would standardize MOUD/MAUD access across institutions and improve continuity of care after discharge — addressing one of the most consequential gaps in the SUD treatment continuum. This structural change would ensure systemic accountability and promote widespread uptake of effective treatments.

In 2008, the Farm and Ranch Stress Assistance Network was created as a support network with resources for farmers and ranchers. Farmworkers - the increasing population of workers that support farmers with labor - were not included in the original population eligible for care. According to a recent study, almost 20% of farm workers reported symptoms of anxiety and 14% reported feeling depressed. The Farm Workers’ Mental Health Act would include farmworkers as an eligible population and make peer-to-peer care an eligible grant activity.

In the United States, as many as 200,000 children are placed in residential treatment facilities each year [1]. Currently, residential treatment facilities for adolescents are largely unregulated, which has created a muddled system with a spectrum of programs that can be life-saving on one end, and abusive on the other. Congress should pass the Stop Institutional Abuse Act to initiate the process of regulating residential treatment for adolescents, including data collection, implementation of best practices, use of evidence-based risk assessment tools, and regular reporting to the federal government [2]. Importantly, SICAA directs the National Academies of Sciences, Engineering, and Medicine to study the use of seclusion, restraints, and restrictive and punitive interventions during treatment [3]. 

Additionally, Congress should authorize the Department of Justice to investigate and prosecute SICAA violations by residential treatment facilities and their affiliates, such as transport services, providing criminal-level sanctions for violations. 

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The Medicaid Inmate Exclusion policy currently excludes both those who are awaiting trial and incarcerated people from Medicaid coverage, regardless of prior eligibility. It has been proven that without medically necessary mental health and addiction treatment, recidivism among these populations increases [1]. 

The Rehabilitation and Recovery During Incarceration Act would give states the ability to allow Medicaid and CHIP to cover mental health and substance use for eligible inmates. According to the Prison Policy Initiative, 40% of the prison and jail population in the United States has a diagnosed mental illness. A large portion of people living in prisons and jails have not been screened for mental illness or substance use disorders and 66% of people in federal prison report not receiving mental health care during incarceration [1]. It is apparent that people who are incarcerated experience “serious psychological distress” due to their incarceration [1]. Congress should pass the Rehabilitation and Recovery During Incarceration Act to get incarcerated people the necessary mental health and addiction treatment they deserve, reduce recidivism, and drive up healthcare in the prison setting.

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